Organization
BLUE DENTAL PLLC
Active
Other names
Agua Dental
Organization subpart
No
Provider details
NPI number
Authorized official
SHAHROUZ AKHAVAN D.D.S. (MANAGER)
(956) 380-2482
Entity
Organization
Contact information
Practice address
2155 RUBEN TORRES BLVD, SUITE 4, BROWNSVILLE, TX 78526
(956) 380-2482
Mailing address
307 E UNIVERSITY DR, EDINBURG, TX 78539-3549
(956) 380-2482
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
25304
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
25304
DENTAL LICENSE NUMBER
TX
Enumeration date
10/12/2015
Last updated
11/04/2015
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